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Guidelines for MSK MRI

July 14, 2020

  • If you don’t know, then ask.
    • We would much rather answer questions up front than try to compensate for a bad scan after the fact.
    • During the day, start with the MSK reading room (4-5739, 4-6547, 5-9076). Overnight, the second call radiology resident is responsible.
  • Pay attention to the localization, and use the localization guides.
  • Look for metal, and adjust the protocol accordingly (see Metal Imaging section).
  • Be sure you are covering the entire area of concern. This is especially important for tumor and infection cases.
  • Pay attention to the fat saturation. Poor fat suppression can render some of these exams almost uninterpretable. Use additional STIR or Dixon sequences if the fat saturation is incomplete.
  • If you don’t know, then ask.

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Shoulder (Routine)

FOV = 14 x 14

​

​

  • See localization guide for correct planes
  • Slice thickness 3.5 mm, Slice gap 0.7 mm (for all sequences)
  • Ax PD FSE fat sat
  • Oblique Sag T1
  • Oblique Cor T2 FSE fat sat
  • Oblique Sag PD FSE fat sat
  • Oblique Cor PD FSE Dixon
  • If with contrast:
    • Pre and Post Ax T1 fat sat
    • Coronal and sagittal T1 post fat sat

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Shoulder

Localization Guide

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Shoulder MR Arthrogram

FOV = 14 x 14

  • See localization guide for correct planes
  • Slice thickness 3.5 mm, Slice gap 0.7 mm (for all sequences)
  • Ax T1 fat sat
  • Oblique Sagittal T1
  • Oblique Cor T1 fat sat
  • Oblique Cor T2 FSE fat sat
  • Oblique Sag T1 fat sat
  • ABER T1 fat sat�

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Shoulder MR Arthrogram

ABER Localization Guide

ABER = ABduction + External Rotation

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Pectoralis Major

FOV = 20 x 20

  • See localization guide for correct planes
  • Slice thickness 3.5 mm, Slice gap 0.7 mm (for all sequences)
  • Ax T1
  • Ax T2 FSE fat sat
  • Cor Oblique T2 FSE fat sat
  • Cor Oblique PD FSE Dixon
  • If with contrast:
    • Pre and Post Ax T1 fat sat
    • Coronal and sagittal T1 post fat sat

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Pectoralis Major

Localization Guide

Coronal

Sagittal

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Chest Wall �FOV = to include region of Interest

  • Slice thickness 4 mm, Slice gap 0.8 mm (for all sequences)
  • Ax T1
  • Cor T1
  • AX PD fat sat Cor PD fat sat (Dixon)
  • Sag STIR
  • If with contrast:
    • Cor T1 fat sat PRE Contrast
    • AX T1 fat sat post
    • Cor T1 fat sat post
    • Sag T1 fat sat post

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Sternum�FOV = to include both sternoclavicular joints

  • See localization guide for correct planes
  • Slice thickness 3.5 mm, Slice gap 0.7 mm (for all sequences)
  • Ax T1
  • Ax T2 fat sat
  • Sag T2 fat sat
  • Coronal T1 (plane of sternum)
  • Coronal STIR (plane of sternum)
  • If with contrast:
    • Pre and Post Ax T1 fat sat
    • Coronal and sagittal T1 post fat sat

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Sternum

Localization Guide

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Elbow (Routine)

FOV = 14 x 14

  • Slice thickness 4 mm, Slice gap 0 mm (for all sequences)
  • Ax T1
  • Ax PD FSE fat sat
  • Cor T2 FSE fat sat
  • Cor PD FSE Dixon
  • Sag PD FSE fat sat
  • If clinical concern for biceps tear:
    • See localization guide for correct planes
    • FABS T1
    • FABS T2 FSE fat sat
  • If with contrast:
    • Pre and Post Ax T1 fat sat
    • Coronal and sagittal T1 post fat sat

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Elbow FABS Sequence

Localization Guide

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Elbow MR Arthrogram

FOV = 14 x 14

​

  • Slice thickness 4 mm, Slice gap 0 mm (for all sequences)
  • Ax T1
  • Ax PD FSE fat sat
  • Cor T1 fat sat
  • Cor T2 FSE fat sat
  • Sag PD FSE fat sat

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Wrist (Routine)

FOV = 10 x 10

  • Slice thickness 3 mm, Slice gap 0.3 mm (for all sequences)
  • Ax PD FSE fat sat
  • Sag PD FSE fat sat
  • Cor T1
  • Cor PD FSE Dixon
  • Cor T2 FSE fat sat
  • If with contrast:
    • Pre and Post Ax T1 fat sat
    • Coronal and sagittal T1 post fat sat

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Wrist MR Arthrogram

FOV = 10 x 10

  • Slice thickness 3 mm, Slice gap 0.3 mm (for all sequences)
  • Ax T1
  • Ax PD FSE fat sat
  • Sag PD FSE fat sat
  • Cor T1 fat sat
  • Cor PD FSE Dixon
  • Cor T2 FSE fat sat

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Hand

FOV = 12 x 12

  • Slice thickness 3 mm, Slice gap 0.3 mm (for all sequences)
  • Ax T1
  • Ax T2 FSE fat sat
  • Cor T1
  • Cor T2 FSE fat sat
  • Cor PD FSE Dixon
  • Sag PD FSE fat sat
  • If with contrast:
    • Pre and Post Ax T1 fat sat
    • Coronal and sagittal T1 post fat sat

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Finger or Thumb

FOV = 10 x 10

  • See localization guide for correct planes for the thumb
  • Slice thickness 3 mm, Slice gap 0.3 mm (for all sequences)
  • Ax T1
  • Ax T2 FSE fat sat
  • Cor T1 (coronal to thumb or finger metacarpal)
  • Cor T2 FSE fat sat (coronal to thumb or finger metacarpal)
  • Sag PD FSE fat sat
  • If with contrast:
    • Pre and Post Ax T1 fat sat
    • Coronal and sagittal T1 post fat sat

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Thumb Localization Guide

Localize the coronal and sagittal relative to the thumb,

prescribe from the axial

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Long Bone Infection or Tumor

FOV = cover entire tumor or area of concern

  • Slice thickness 4 mm, Slice gap 0.8 mm (for all sequences)
  • Ax T1
  • Ax PD FSE fat sat
  • Cor T1
  • Sag STIR
  • Cor PD FSE Dixon
  • If with contrast:
    • Pre Coronal T1 Fat Sat
    • Post-contrast Ax, Cor, Sag T1 fat sat

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Pelvis (MSK)�FOV = Large – entire pelvis

  • Slice thickness 3.5 mm, Slice gap 0.7 mm (for all sequences)
  • Cor T1
  • Cor STIR
  • Cor PD FSE Dixon
  • Ax T1
  • Ax T2 FSE fat sat
  • If with contrast:
    • Pre and Post Ax T1 fat sat
    • Coronal and sagittal T1 post fat sat

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Pelvis

(Athletic Pubalgia, Sports Hernia, Symphysis)

  • FOV = Large – entire pelvis
  • Slice thickness 3.5 mm, Slice gap 0.7 mm (for all sequences)
  • Cor T2 FSE fat sat
  • Cor T1
  • FOV = 24 x 24 – centered over pubic symphysis (see localization guide)
  • Ax T1
  • Oblique Ax T2 FSE fat sat
  • Sag T2 FSE fat sat
  • Sag T1

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Pelvis localization guide

(Athletic Pubalgia, Sports Hernia, Symphysis)

Coronal oblique images are aligned parallel to the

pubic bones/symphysis pubis (arrow)

Appearance of coronal oblique image

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Hip (routine)

  • FOV = 38 x 38 (image sacrum & both hips)
  • Slice thickness 4 mm, Slice gap 0.8 mm
  • Cor T1
  • Cor STIR or T2 FSE fat sat
  • Ax T2 FSE fat sat
  • FOV = 18 x 18 (image affected hip)
  • Slice thickness 3.5 mm, Slice gap 0.5 mm
  • Oblique Ax PD FSE fat sat
  • Cor PD FSE Dixon
  • Sag PD Fat Sat

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Hip MR Arthrogram

  • FOV = 38 x 38 (image sacrum & both hips)
  • Slice thickness 4 mm, Slice gap 0.8 mm
  • Cor T1
  • Cor STIR or T2 FSE fat sat
  • Ax T2 FSE fat sat
  • FOV = 18 x 18 (image affected hip)
  • Slice thickness 3.5 mm, Slice gap 0.5 mm
  • Ax PD FSE fat sat
  • Cor T1 fat sat
  • Cor T2 FSE fat sat
  • Oblique Ax T1 fat sat
  • Sag T1 fat sat

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Hip localization guide

Axial oblique of the hip is aligned along the femoral neck

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Sacrum

FOV = include entire sacrum, coccyx and both SI joints

  • See localization guide for correct planes
  • Slice thickness 4 mm, Slice gap 0.8 mm (for all sequences)
  • Cor oblique T1
  • Cor oblique STIR
  • axial T2 fat sat
  • Sag T1
  • Sag PD fat sat
  • If with contrast:
  • Pre and Post Ax T1 fat sat
  • Coronal and sagittal T1 post fat sat

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Sacrum localization guide

Axial is perpendicular to the sagittal

ax

Cor

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Knee (Routine)

FOV = 16 x 16

  • Slice thickness 3.5 mm, Slice gap 0.7 mm (except thin meniscal sequence)
  • Ax PD FSE fat sat
  • Sag PD FSE fat sat
  • Cor PD FSE Dixon
  • Cor T2 FSE fat sat
  • Cor T1 FSE
  • Thin meniscal Ax PD fat sat- Only through menisci- See localization guide�Slice thickness 1 mm (or as thin as possible), No slice gap (Slice gap 0 mm)
  • If with contrast:
    • Pre and Post Ax T1 fat sat
    • Coronal and sagittal T1 post fat sat

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Knee meniscal sequence

localization guide

Align parallel to the tibial plateau using both coronal and sagittal as a guide

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Knee MR Arthrogram

FOV = 16 x 16

​

  • Slice thickness 3.5 mm, Slice gap 0.7 mm (except thin meniscal sequence)
  • Ax T2 FSE fat sat
  • Sag PD FSE
  • Cor PD FSE Dixon
  • Sag T1 fat sat
  • Cor T1 fat sat
  • Cor T1 FSE
  • Thin meniscal Ax PD fat sat- Only through menisci- See localization guide�Slice thickness 1 mm (or as thin as possible), No slice gap (Slice gap 0 mm)

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Ankle (Routine)

FOV = 16 x 16

  • Slice thickness 3 mm, Slice gap 0.6 mm (for all sequences)
  • Ax T1
  • Ax T2 FSE fat sat
  • Cor PD FSE Dixon
  • Sag T1
  • Sag STIR
  • If with contrast:
    • Pre and Post Ax T1 fat sat
    • Coronal and sagittal T1 post fat sat

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Ankle MR Arthrogram

FOV = 16 x 16

  • Slice thickness 3 mm, Slice gap 0.6 mm (for all sequences)
  • Ax T1 fat sat
  • Ax T2 FSE fat sat
  • Cor T1 fat sat
  • Cor PD FSE Dixon
  • Sag T1
  • Sag STIR

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Foot (Hindfoot)

FOV = 16 x 16

​

  • Slice thickness 3 mm, Slice gap 0.6 mm (for all sequences)
  • Ax T1
  • Ax T2 FSE fat sat
  • Cor PD FSE Dixon
  • Sag T1
  • Sag STIR
  • If with contrast:
    • Pre and Post Ax T1 fat sat
    • Coronal and sagittal T1 post fat sat

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Foot (Midfoot or Forefoot)

FOV = variable (as small ass possible)

  • See localization guide for imaging planes
  • Slice thickness 3 mm, Slice gap 0.6 mm (for all sequences)
  • Cor Oblique T1 (long axis of foot; in plane of metatarsals)
  • Cor Oblique T2 FSE fat sat (long axis of foot; in plane of metatarsals)
  • Ax PD FSE fat sat (short axis of foot)
  • Ax T1 (short axis of foot)
  • Sag T1
  • Sag STIR
  • If with contrast
    • Pre and Post Ax T1 fat sat (short axis)
    • Coronal and sagittal T1 post fat sat

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Foot (Midfoot & Forefoot)

localization guide

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Metal Imaging

(Rods, Plates, Arthroplasties, Etc.)

  • Scan patient on 1.5T magnet, not 3T
  • Increase bandwidth
  • Substitute STIR for all T2 fat sat sequences
  • Substitute PD Dixon or STIR for all PD fat sat sequences
  • Add T2 Axial
  • If with contrast:
    • Axial or Coronal T1 fat sat pre-contrast
    • Axial or Coronal T1 fat sat post contrast (same plane as T1 fat sat pre-contrast)
    • T1 post contrast without fat sat in the other two planes